Failure to Implement and Monitor Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents who required fluid restrictions as part of their treatment. For one resident with a physician's order for a 1000 ml daily fluid restriction, the medical record and Medication Administration Record (MAR) did not document the specific amount of fluid consumed in milliliters, only showing check marks for monitoring. There was also no documentation in the progress notes of the resident's fluid intake per shift or per day. During observation, an open can of carbonated drink was found at the resident's bedside, and the assigned CNA was unaware of the fluid restriction, stating that this information was not communicated during shift change or by the charge nurses. The ADON confirmed the lack of documentation and communication regarding the fluid restriction, and acknowledged that unmonitored fluids should not be present at the bedside for residents on fluid restrictions. For the second resident, who had a physician's order for a 1500 ml daily fluid restriction, observations revealed a water pitcher, glass of water, soda cans, and bottles of flavored drinks at the bedside. The resident's fluid intake records for the past 30 days showed daily totals that exceeded the prescribed dietary fluid intake, with some days reaching 1440 ml from meal trays alone. The MAR again only showed check marks for monitoring, without specific amounts documented. The CNA assigned to the resident was aware of a fluid limit but did not know the exact amount, and verified the presence of multiple fluid sources at the bedside. The RN confirmed that the recorded fluid intake was not accurate, as only dietary fluids were documented and nursing-provided fluids were not consistently recorded. The DON verified these findings during review. The facility's policy and procedure for encouraging and restricting fluids required staff to follow specific instructions for fluid intake, accurately record intake in milliliters, remove water pitchers and cups from rooms of residents on fluid restrictions, and maintain intake and output records. These procedures were not followed for either resident, resulting in a failure to ensure physician's orders for fluid restrictions were implemented and monitored as required.